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Friday, September 20, 2019

Physicians as Guardians of Society's Resources-

In the early part of the second half of the 20th century when I received by medical education,physicians were taught they had a fiduciary duty to their patients. There was for the most part no third party obligations. There were no major presence of HMOs at that time.Richard Nixon changed that.

As medical care costs and expenditures increased, third party payers including the growing HMOs and large corporations who provided health insurance (some were self-insured) took measures to control costs. There were larger deductibles and co-payments and more scrutiny by insurance companies on what exactly they would pay for. There were guidelines and pre approval rules for testing. These counter measures probably helped somewhat but costs continued to rise and continue they would as basically this was folks spending someone else's money and the fingers on the cost gun were in the hands of hundred of thousands of physicians.

The problem was how to control the activities on these physicians who had been schooled for many decades with the ethical imperative of do what is right for the patient. For physicians trained in that ethical environment, cost to the " system", be it United Health Care,Exon, or Medicare,was not a major priority in their value system or decision making calculus.

So various variations of carrots and sticks were employed by the third party payers.Pay for performance grew up as a type of bribe to docs to follow the cost cutting guidelines which went by the wink,wink,nudge, nudge name of quality guidelines.

Although carrot and stick techniques have a proven history of changing behaviors to some degree,what is even better is to have as the triggers of medical cost initiation i.e physicians (or some alternative "health care provider, eg NP, PA)) folks who really believe their duty lies at least to a significant operational degree in cost saving.Clearly to the third party payers physicians had their priorities all mixed up.

Enter the concept of physicians as stewards of society's resources.

I have not devolped a detailed chronology of that part of the literature which deals with medical policy matters to be able to date with any precision when and how this concept arose. I have written before on some of the earlier papers in the mainstream medical literature.

In 1988 Hall and Berenson writing in the Annals of Internal Medicine said that "the traditional ideal" [the prime duty to the patient ] was "not compatible with the role that existing insurance contracts and manged care arrangements define for physicians." Their comments were not subtle when they said :

We propose that devotion to the best interests of each individual be replaced with an ethic of devotion to the best interests of the group for which the physician is personally responsible.

Note-now we are talking about a benefit to a specific HMO or PPO and not in the benefit of some abstract "society" yet often the arguments for the new ethics is framed in terms of benefits to society.

Note:Berenson glibly justifies that sea change because the role that insurance contract define for the physicians. Here we might pause and remember that one of the defining characteristics of a profession is that members are bound by a ethical code that is largely self defined.Now it seems that medical ethics should be defined by insurance company interests.

Over the next 20 years far from that proposal being dismissed out of hand as medical ethical heresy which is how many of us at the time would have characterized it, it has become part of the generally accepted medical ethical package nestled in professionalism statements by most medical organizations and has become or is becoming part of medical education .

The fiduciary duty to the patients seem to have been demolished ( or at least made secondary) without much more that the occasional outcry by physicians of the old school. Various attempts to resist this over turning of traditional medical ethics have not prevailed. The dogs bark and the caravan moves on.

We have traveled a long way since the Berenson article.Now we read of a suggestion that "cost-consiousness and stewardship of resources be elevated by the ACGME and the ABMS to the level of a a new seventh general competency." In other words, residents should be schooled and graded on their mastery of the skill set necessary to be good stewards of [society's] resources. ( reference, The Idea and Opinions Section, Annals of Internal Medicine,20 Sept 2011,Vol.155 no.6, by Dr. Steven E. Weinberger,of the American College of Physicians.